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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE >A owe COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL. RECORDS
<br />DATE 1/7/2020
<br />�0 ANCE RUSSELL FOSLER
<br />8 1 i SISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />LINCOLN, NEBRASKA
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />December 17, 2019
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Eurdis L Willis
<br />2. SEX
<br />Female
<br />4, CITY AND STATE TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Dannebroq, Nebraska
<br />So, AGE, Last Birthday
<br />(Yrs.)
<br />90
<br />Sb. UNDER 1 YEAR
<br />Sc. UNDER I DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />6. DATE OF BIRTH (Mo.r Day, Yr-}.::
<br />September 30, 1929
<br />5 7. SOCIAL SECURITY NUMBER
<br />a
<br />..506-30-4833
<br />Y 8b. FACILITY -NAME (If not Institution, give street and number)
<br />0
<br />v
<br />m
<br />2� d i;tere ieree rhtt?
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />0 ER/Outpatient
<br />rrl nrt q
<br />OTHER 0 Nursing Home/LTC
<br />® Decedent's Home
<br />1 _1 not., ISent, vl
<br />0 Hospice Facility
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68801
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />2428 Commerce Ave
<br />9b. COUNTY
<br />Hall
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand > Island
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS
<br />® YES ❑ NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />❑ Married, but separated ❑ Widowed 0 Divorced 0 Unknown
<br />40b.:NAME OF_SPOUSE :(First, Middle, Last, Suffix) If wife, give maiden name
<br />Richard Willis
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix) 12. MQTHER`S-NAME (First, Middle,
<br />Arnold Niemoth Elsie Bennet
<br />Maiden Surname)
<br />13. EVER IN U.S.: ARMED FORCES? Give dates of service If Yes.
<br />(Yes, No, or Unk.) No
<br />IS. METHOD OF ,DISPOSITION
<br />® Bural ❑ Donation
<br />❑ Cremation 0 Entombment
<br />❑ Removal 0 Other (Specify)
<br />14a. INFORMANT -NAME
<br />Richard Willis
<br />16a. EMBALMER -SIGNATURE
<br />Katie M. Smvdra
<br />18b LICENSE NO.
<br />1454
<br />14b. RELATIONSHIP TO DECEDENT
<br />Husband
<br />16c. DATE (Mo Day Yr,)
<br />December 23, 2019
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Grand Island City Cemetery
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home. 2929 S. Locust Street. Grand Island. Nebraska
<br />CITY / TOWN
<br />Grand Island
<br />STATE
<br />Nebraska
<br />17b, Zip'Code
<br />68801
<br />CAUSE OF DEATH (See Instructions and examples)
<br />R PART I. enter the: Chain of agents- -diseases, injuries, or complications -that directly cawiad the death. DO NOT enter terminal events such as cardiac arrest,
<br />reapiretory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line, Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />iC IMMEDIATE CAUSE (Final a) Unknown Natural Causes
<br />e disease or condition resulting
<br />a
<br />0
<br />0
<br />W
<br />esC
<br />es
<br />is
<br />In death)
<br />Sequentially list conditions, If
<br />any, leading to the cause listed
<br />on line a
<br />Enter the UNDERLYING CAUSE
<br />{disease dr injurythat Initialed
<br />the events Writhing in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) Dementia
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />APPROXIMATE INTERVAL:
<br />onset to death
<br />Immediate
<br />onset to -death
<br />Years
<br />onset to death
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />Hypertension
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />YES Q (40
<br />20.1F FEMALE:
<br />❑ Not pregnant within past year
<br />0 Pregnant at time of death
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregning, but pregnant 43 days to 1 year before death
<br />❑ Unknown if pregnant within the past year
<br />21a. MANNER OF DEATH
<br />Natural 0 Homicide
<br />0 Accident ❑ Pending Investigation
<br />❑ Suicide 0 Could bot bet determined
<br />21b. IF TRANSPORTATION INJURY
<br />0 orlerlOperator
<br />0 Passenger
<br />❑ Pedestrian
<br />❑ Other IsPeelbh
<br />21c. WAS AN AUTOPSY PERFORMER?
<br />❑ YES ® NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF Darren?
<br />❑YES ❑NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑YES NO
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO.
<br />CITY/TOWN
<br />STATE
<br />ZIP CODE
<br />ffi
<br />Eu 5
<br />O
<br />234, DATE OFMEATH (Mo„ Day, fr.)
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />23c. TIME OF DEATH
<br />23d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature and Title) - -
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES ❑ NO 0 PROBABLY ® UNKNOWN
<br />CrnPofl (am flay Yr 1 I
<br />st December 20. 2019
<br />I24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />f2
<br />E3 ZZ December 17, 2019
<br />1 0 z O 24e. On the basis of sxaminalion and/or investigation, in my opinion death occurred at
<br />$ p the time, date and place and due to the causes) stand. (Signature and Title)
<br />8 t33 Sarah Hinrichs, Hall Deputy County Attorney
<br />24b. TIME OF DEATH
<br />Unknown
<br />24d. TIME PRONOUNCED DEAD
<br />09:23 AM
<br />28a. HAS ORGAN OR TISSUE DONATION Beets CONSIDERED?
<br />❑YES RINO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 28a Is NO ❑ YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Sarah Hinrichs, Hall Deputy County Attorney, 231 S. Locust, Grand Island, Nebraska, 68801
<br />28a.REGISTRAR;
<br />SIGNATURE
<br />28b. DATE FILED BY REGISTRAR(Mo,, Day, Yr.)
<br />December 31, 2019
<br />
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